3rd Satisfaction Disability & Discharge (Motor)

ymt¥m¾ c’É ¼dNb¾¼
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
”w[ƒ’~ ¾ ¾J’ ´`´\ ŸLÃ ¾}Ökc¨< }iŸ`"] k” ¯.M. u¡MM ¨[Ç

M¿ eS< _________________________
u}vK xታ uÅ[cuƒ ›ÅÒ U¡”Áƒ y_gÂ êUWN k?BrT x!N¹#‰NS x.¥ yµœ KFÃ
w`_______________________________ የ}kuMŸ<&SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</
እ“[ÒÓ×K”:: ቀሪዉን 25% ቅሪተ xµL SmLS እ“ }iŸ`"]¬ }ÖÓ• c=Ö“kp yMNwSD YçÂL::
k” _______________________________ ò`T _______________________
›T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
mt¥m¾ c’É ¼Å”u—¼
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
”w[ƒ’~ ¾ ¾J’ ´`´\ ŸLÃ ¾}Ökc¨< }iŸ`"] k” ¯.M. u¡MM

¨[Ç M¿ eS< _____________ u}vK x ታ uÅ[cuƒ ›ÅÒ U¡”Áƒ xeðLÑ>¨< ØÑ“ }Å`ÔKƒ eK}
[ŸwŸ< MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›.T ¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹”
›[ÒÓ×KG</እ“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
እ T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< ________________________u}vK x ታ uÅ[cuƒ ›ÅÒ U¡”Áƒ y_gÂ ዋጋ በችሮታ ?BrT
x!N¹#‰NS x.¥ yµœ KFÃ w`________________________________________ eK}kuMŸ<&u²=I ›ÅÒ
UŸ”Áƒ MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T ¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹”
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
የመተማመኛ ሰነድ (ደንበኛ)
WK?Ç lØ`:_____________________________________
V}` lØ`: __________________________________________
‰c= lØ`: ___________________________________________
ªeƒ“ lØ`: _______________ ¾"X lØ`: ___________
ንብረትነቱ የ__________________________________________ የሆነ ዝርዝሩ ከላይ የተጠቀሰው

ተሽከርካሪ___________________ቀን_____________በክልል___________ወረዳ__________ልዩ
ስሙ_________________________ በተባለ ቦታ vÅ[c¨< ¾fe}— ¨Ñ” ¾”w[ƒ ›ÅÒ ወጭውን ብር
___________________________________________ስለተቀበልኩ በዚህ አደጋ ምክንያት ምንም አይነት
ተጨማሪ ካሣ ŸQw[ƒ ›”g<^”e ›T የማልጠይቅ መሆኔን በተለመደው ፊርማዬ/ፊርማችን
አረጋግጣለሁ/እናረጋግጣለን፡፡
k”_______________________________ ò`T_____________________
T™‹
1. _________________________________________
ò`T_____________________
2. _________________________________________ ò`T____________________
3. _________________________________________ ò`T_______________________
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
”w[ƒ’~ ¾______________________________________________________ ¾J’ ´`´\ ŸLÃ

¾}Ökc¨< }iŸ`"] k” ¯.U. u¡MM . ¨[Ç M¿ eS<
_________________________________________ u}vK x uÅ[cuƒ xdU lt>kRµ¶W
¥S-g¾Â l@lC tÃÃ™ wÀãCN w`_____________________________________________ ŸQw[ƒ
›=”g<^”e ›T b²ÊW :lT SK}kuMŸ<& u²=I ›ÅÒ UŸ”Áƒ b ፍ RD b@T jMÊW ynbrWN KS ÃöMk# XÂ
l@§ U”U ›Ã’ƒ }ÚT] "X ŸQw[ƒ ›=”g<^”e ›T ¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹”
›[ÒÓ×KG</“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
mt¥m¾ c’É ¼ ሶስተኛ ወገን ¼
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
´`´\ ŸLÃ ¾}Ökc¨< ”w[ƒ’~ ¾ ኢንሹራንስ ኩባንያዉ ደንበኛ የ የሆነ ተሸከርካሪ ¾ እኔ በ

የሰሌዳ ቁጥር }iŸ`"] ላይ በ k” ¯.M. u¡MM ¨[Ç M¿ eS<
_____________ u}vK xታ ባ Å[cuƒ የግጭት ›ÅÒ U¡”Áƒ የ ØÑ“ ዋጋዉን ብር
eK}ቀበኩ በዚህ አደጋ ምክንያት MNM xYnT t=¥¶ "X ከደንበኛችሁም ሆነ ŸQw[ƒ ›=”g<^”e ኩባንያ ›.T
¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</እ“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
እ T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
mt¥m¾ c’É ¼îSt¾ wgN¼
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :_____________________

¨[Ç M¿ eS< __________________________________________________________ u}vK x ታ
uÅ[cuƒ ›ÅÒ U¡”Áƒ xeðLÑ>¨< ØÑ“ }Å`ÔKƒ eK}[ŸwŸ</uS[ØŸ<ƒ KTW^ƒ ¨ß¨<”
w`______________________________eK}kuMŸ<&u²=I ›ÅÒ UŸ”Áƒ MNM xYnT t=¥¶ "X ŸQw[ƒ
›=”g<^”e ›T J’ ŸÅ”u—‹G< ŸWK?Ç lØ`________________ SŸ=“ vKu?ƒ“ ›iŸ`"]
¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
UNDERTAKING
Registration No.: ____________________________________
Engine No.: __________________________________________
Chassis No.: _________________________________________
Policy No._______________ Claim No.:___________
I/we the undersigned agreed/confirmed to repair the above mentioned vehicle at the bid winner
___________________________Garage.
Date_______________________________ Signature_______________________
Witness
______________________
____________ Signature_______________________
__________________________________ Signature_______________________
_____________________
_____________ Signature_______________________
Disa/Disch.F/M1
UNDERTAKING
Registration No.: ____________________________________
Engine No.: __________________________________________
Chassis No.: _________________________________________
I/we the undersigned agreed/confirmed to collected mount of _______________________for damaged electric pol
check No entire satisfaction and hereby discharge The United Insurance Company S.C. o
claims I lodged in regard to the above property.
Date_______________________________ Signature_______________________
Witness
______________________
____________ Signature_______________________
__________________________________ Signature_______________________
______________________
____________ Signature_______________________
Disa/Disch.F/M1
?BrT x!N¹#‰NS k#ÆNÃ x.¥.
ymt¥m¾ \nD
Xn@ S» kz!H b¬C yt-qsW y\l@Ä q$_R t>kRµ¶ Ælb@T
yçNk# mk!Âü b ›.M bdrsbT xdU MKNÃT k_QM W+ bmçn#¿ b?
BrT x!N¹‰NS x.¥ Æl" ymDN >ÍN m\rT yx-”§Y WDmT yµœ KFÃ BR
b²ÊW :lT k?BrT x!
N¹#‰NS x.¥. ytqbLk# s!çN bz!H xdU ydrsWN g#ÄT btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?
BrT x!N¹#‰NS x.¥. y¥L-YQ mçn@N bðR¥ü xrUGÈlh#ÝÝ
SM
ðR¥. .
qN . .
X¥®C¿
X¾ S¥CN kz!H b¬C yt-qsW X¥®C xè¼w¼é¼T k§Y yt-qsWN SMMnT
wdWÂ fQdW mfr¥cWN XNÄ!h#M BR k?BrT x!
N¹#‰NS x.¥.mqb§cWN ¥y¬CNN XÂrUGÈlNÝÝ
SM ðR¥
1. .
2. . .
3. .

Disa/Disch.F/M1
ymt¥m¾ \nD
Xn@ S» kz!H b¬C yt-qsW¿ b ›.M. NBrTnt$ y .
yçnWÂ y\l@Ä q$_„ bçn t>kRµ¶ xè¼w¼é¼¶T §Y

ÆdrsWT xdU MKNÃT l!kfL y¸gÆWN የሕክምና ሙሉ ወጪ KFÃ BR
. b²ÊW :lT k?BrT x!N¹#‰NS k#ÆNÃ x.¥. wDËÂ fQË mqbl@N
Xygl{k#¿ YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#‰NS x.¥. y¥L-YQ
mçn@N bðR¥ü xrUGÈlh#ÝÝ
SM
ðR¥. .
qN . .
X¥®C¿
X¾ S¥CN kz!H b¬C yt-qsW X¥®C w¼é¼xè .k§Y yt-qsWN SMMnT
SM ðR¥
1. .
2. . .
3. .

ymt¥m¾ \nD
Disa/Disch.F/M1
yçnWÂ y\l@Ä q$_„ yçn t>kRµ¶ b §Y ÆdrsW yG+T

xdU MKNÃT l!kfL y¸gÆWN yµœ KFÃ BR .
b²ÊW :lT k?BrT x!N¹#‰NS k#ÆNÃ x.¥. bµ> wDËÂ fQË mqbl@N Xygl{k#¿ YHNN xdU
btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM
kx>kRµ¶W y¥L-YQ mçn@N bðR¥ü xrUGÈlh#ÝÝ
SM
ðR¥. .
qN . .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .

ymt¥m¾ \nD
Disa/Disch.F/M1
b ›.M. NBrTnt$ y . yçnWÂ y\l@Ä q$_„ yçn
t>kRµ¶ b §Y ÆdrsW yG+T xdU MKNÃT l!kfL y¸gÆWN የወጪና
ገቢ ኪሣራ BR . b²ÊW :lT k?BrT x!N¹#‰NS
k#ÆNÃ x.¥. bµ> wDËÂ fQË mqbl@N Xygl{k#¿ YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ
_Ãq& k?BrT x!N¹#‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ mçn@N
bðR¥ü xrUGÈlh#ÝÝ
SM
ðR¥. .
qN . .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
Disa/Disch.F/M1
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
”w[ƒ’~ ¾______________________________________________________ ¾J’ ´`´\ ŸLÃ

¾}Ökc¨< }iŸ`"] k” ¯.U. u¡MM . ¨[Ç M¿ eS<
_________________________________________ u}vK x uÅ[cuƒ ›ÅÒ uS[ØŸ<ƒ Ò^»
l¥\‰T bQD¸Ã y_gÂWN 50% wÀ¨<” w`__________________
y}kuMŸ< s!çN q¶WN 50% mk!ÂW ytmzgb Slçn y_gÂW |‰ m-Âqq$ k¬y b“§
XNÄ!kfl" ytS¥¥h# SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
DISCHARGE RECEIPT (insured)
Registration No.: ____________________________________
Engine No.: __________________________________________
Disa/Disch.F/M1
Chassis No.: _________________________________________
I/we the undersigned having received the above mentioned vehicle repaired to my/our having been paid
the amount of E.Br.______________________________ for the payment to 75% of repairing cost
hereby discharge the remaining 25% ETB ____________ will be collected after finalization of repairing
to the vehicle. The United Insurance Company SC and the owner of the vehicle of any liability
whatsoever in connection with and/or in consequence of the above mentioned accident.
Date_______________________________ Signature_______________________
Witness
______________________
____________ Signature_______________________
__________________________________ Signature_______________________
_____________________
_____________ Signature_______________________
Disa/Disch.F/M1
0
y`¡¡w c’É
DISCHARGE RECEIPT (Insured)
WK?Ç lØ`/ Registration No.: _____________________________________
V}` lØ`/Engine No.: __________________________________________
‰c= lØ`/Chassis No.: ___________________________________________
ªeƒ“ lØ`/Policy No._______________ ¾"X lØ`/Claim No.:___________
Xn@ S» kz!H b¬C yt-qsW ZRZ„ kz!H b§Y yt-qsW }iŸ`"¶ ÆlNBrT SçN¿ k§Y yt-qsW t>kRµ¶
k” ¯.M. u¡MM ¨[Ç M¿ eS< u}vK x uÅ[cuƒ ›ÅÒ t>kRµ¶WN l¥S-gN
¨ß¨<” w` ________________________________________ b²ÊW XlT k?BrT x!N¹#‰NS x.¥.
eK}kuMŸ<& u²=I ›ÅÒ UŸ”Áƒ U”M xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T ¾TMÖÃp SJ’@”
u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</“[ÒÓ×K”::
k”/Date_______________________________ ò`T/Signature_______________________
T™‹/Witness
1.
_________________________________________ ò`T/Signature_______________________
2. _________________________________________ ò`T/Signature_______________________
3. _________________________________________ ò`T/Signature_______________________
Disa/Disch.F/M1
¾`¡¡w c’É
DISCHARGE RECEIPT (Insured)
V}` lØ`/Engine No.: __________________________________________
‰c= lØ`/Chassis No.: ____________________________________________
ªeƒ“ lØ`/Policy No._______________ ¾"X lØ`/Claim No.:_______
”w[ƒ’~ ¾________________________________________________________________
¾J’ ´`´\ ŸLÃ ¾}Ökc¨< }iŸ`"] k” ¯.U. u¡MM ¨[Ç M¿ eS<
_________________________________________ u}vK x uÅ[cuƒ
uS[ØŸ<ƒ Ò^» KTW^ƒ ¨ß¨<”
w`___________________________________________________________________________
eK}kuMŸ<& yxµL _gÂ wÀN btmlkt U”U ›Ã’ƒ }ÚT] "X ŸQw[ƒ ›=”g<^”e ›T ¾TMÖÃp SJ’@”
u}KSÅ¨< ò`TÂ ›[ÒÓ×KG</“[ÒÓ×K”::
T™‹/Witness
1.
_______________________________ ò`T/Signature_______________________
2.
_______________________________ ò`T/Signature_______________________
3.
_______________________________ ò`T/Signature_______________________
Disa/Disch.F/M1
y`¡¡w c’É
DISCHARGE RECEIPT
V}` lØ`/Engine No.: __________________________________________
‰c= lØ`/Chassis No.: ___________________________________________
”w[ƒ’~ ¾ ¾J’ ´`´\ ŸLÃ ¾}Ökc¨< }iŸ`"] k”

¯.M. u¡MM ¨[Ç M¿ eS< u}vK x uÅ[cuƒ
›ÅÒ U¡”Áƒ b-Q§§ WDmT XNÄ!StÂgD çñ ¨ß¨<” w` _____________________________________
eK}kuMŸ</ u²=I ›ÅÒ UŸ”Áƒ MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T J’ ŸÅ”u—‹G< ŸWK?Ç lØ`
SŸ=“ vKu?ƒ“ ›iŸ`"] ¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</“[ÒÓ×K”::
I/we the undersigned having received the above mentioned vehicle entrtained as a total loss to
my/our full satisfaction or having been paid the amount of E.Br.
do hereby discharge The United Insurance Company SC and
the owner of the vehicle of any liability whatsoever in connection with and/or in consequence of
the above mentioned accident.
T™‹/Witness
______________________
____________ ò`T/Signature_______________________
__________________________________ ò`T/Signature_______________________
_____________________
_____________ ò`T/Signature_______________________
y`¡¡w c’É
Disa/Disch.F/M1
DISCHARGE RECEIPT
V}` lØ`/Engine No.: __________________________________________
‰c= lØ`/Chassis No.: ___________________________________________
”w[ƒ’~ ¾ ¾J’ ´`´\ ŸLÃ ¾}Ökc¨< }iŸ`"] k”

¯.M. u¡MM ¨[Ç M¿ eS< u}vK x uÅ[cuƒ
›ÅÒ U¡”Áƒ xSf§g!W _gÂ tdRgÖlT ¨ß¨<” w` _____________________________________
eK}kuMŸ</ u²=I ›ÅÒ UŸ”Áƒ MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T J’ ŸÅ”u—‹G< ŸWK?Ç lØ`
I/we the undersigned having received the above mentioned vehicle repaired to my/our full
satisfaction or having been paid the amount of E.Br. _
do hereby discharge The United Insurance Company SC and
the owner of the vehicle of any liability whatsoever in connection with and/or in consequence of
the above mentioned accident.
T™‹/Witness
______________________
____________ ò`T/Signature_______________________
__________________________________ ò`T/Signature_______________________
_____________________
_____________ ò`T/Signature_______________________

ymt¥m¾ \nD
Disa/Disch.F/M1
Xn@ S» kz!H b¬C yt-qsW¿ b ›.M. NBrTnt$
yçnWÂ y\l@Ä q$_„ bçn t>kRµ¶
§Y ÆdrsW yG+T xdU MKNÃT l!kfL y¸gÆWN y ህክምና ወጪ እና ቋሚ የአካል ጉዳት የካሳ ክፍያ
BR b²ÊW :lT k?BrT x!N¹#‰NS k#ÆNÃ x.¥. b_Ê gNzB wDËÂ
fQË mqbl@N XgLÉlý
SM
ðR¥. .
qN . .
X¥®C¿
X¾ S¥CN kz!H b¬C yt-qsW X¥®C xè k§Y yt-qsWN SMMnT
wdWÂ fQdW mfr¥cWN XNÄ!h#M BR k?BrT x!N¹#‰NS x.
¥. mqb§cWN ¥y¬CNN XÂrUGÈlNÝÝ
SM ðR¥
1. .
2. . .
3. .
Disa/Disch.F/M1
ymt¥m¾ \nD
§Y ÆdrsW yG+T xdU MKNÃT l!kfL y¸gÆWN y ህክምና yµœ KFÃBR
b²ÊW :lT k?BrT x!N¹#‰NS k#ÆNÃ x.¥. b_Ê gNzB wDËÂ fQË mqbl@N
SM
ðR¥. .
qN . .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .

Disa/Disch.F/M1
ymt¥m¾ \nD
§Y ÆdrsW yG+T xdU MKNÃT l!kfL y¸gÆWN yäT yµœ KFÃBR
b²ÊW :lT k?BrT x!N¹#‰NS k#ÆNÃ x.¥. b_Ê gNzB wDËÂ fQË mqbl@N
Xygl{k#¿ YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#‰NS x.¥. çn
kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ mçn@N bðR¥ü xrUGÈlh#ÝÝ
SM
ðR¥. .
qN . .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .

ymt¥m¾ \nD
Xn@ S» kz!H b¬C yt-qsW¿ b ›.M. NBrTnt$ y yçnWÂ y\
l@Ä q$_„ bçn t>kRµ¶ ›„/¨/a/]ƒ
Disa/Disch.F/M1
§Y ÆdrsW yG+T xdU l!kfL y¸gÆWN yµœ KFÃ BR
b²ÊW :lT ŸTÃc\ ÖpLL ”ÓÉ .¾}.¾Ó.TIu` LÃ b_Ê gNzB
wDËÂ fQË mqbl@N Xygl{k#¿ YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& ŸSÉ” cÜ¨< k?
BrT x!N¹#‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ mçn@N bðR¥ü
Á[ÒÑØŸ< Ã¦¨< ¡õÁ uSÉ” Ñu=¨< uŸ<M u³_¨< °Kƒ uQw[ƒ ›=”g<^”e ›.T uSp[w ¾Ÿ<u”Á¨<
vMÅ[x‹ u}Ñ–<uƒ ¾}Ÿ“¨’M˜ SJ’<” ›[ÒÓ×KG<::
SM
ðR¥. .
qN . .
X¥®C¿
wdWÂ fQdW mfr¥cWN XNÄ!h#M BR
kTÃc\ ÖpLL ”ÓÉ .¾}.¾Ó.TIu` mqb§cWN ¥y¬CNN XÂrUGÈlNÝÝ
SM ðR¥
1. .
2. . .
3. .
4.--------------------------------------------------- .---------------------------------------
ymt¥m¾ \nD
Xn@ S» kz!H b¬C yt-qsW¿ b ›.M..b?BrT x!N¹#‰NS k#ÆNÃ x.¥
ymDN >ÍN ÆlW y\l@Ä q$_R ÷D t>kRµ¶ bdrsB" y_RS WL”T xdU
_Rs@ mtkl#NÂ XNÄ!h#M kz!H UR tÃÃ™nT Ã§cWN wÀãC BR
b²ÊW :lT k?BrT x!N¹#
‰NS x.¥.wDËÂ fQË mqbl@N Xygl{k#¿ YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?
BrT x!N¹#‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ mçn@N bðR¥ü
xrUGÈlh#ÝÝ
Disa/Disch.F/M1
SM
ðR¥. .
qN . .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .
ymt¥m¾ \nD
Xn@ S» kz!H b¬C yt-qsW¿ b ›.M..b?BrT x!N¹#‰NS k#ÆNÃ x.¥
ymDN >ÍN ÆlW y\l@Ä q$_R ÷D t>kRµ¶ túFÊ úl bt>kRµ¶W §Y
bdrsbT ymgLb_ xdU MKNÃT ldrsB" yxµL g#ÄT kçSpE¬L bts-" y»Ä!µL ïRD \RtFk@T m\rT l!
kfl" y¸gÆWN ym=rš yµœ KFÃ BR
b²ÊW :lT k?BrT x!N¹#‰NS x.¥.wDËÂ fQË mqbl@N
Xygl{k#¿ YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#‰NS x.¥. çn
kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ mçn@N bðR¥ü xrUGÈlh#ÝÝ
Disa/Disch.F/M1
SM
ðR¥. .
qN . .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .

ymt¥m¾ \nD
Xn@¼X¾ S»¼S¥CN kz!H b¬C ytgliW¿ y w§J¼íC¼ xúÄg!¼?
UêE w‰> SçN¿ t-”¹# b ›.M. b?BrT x!N¹#‰NS ymDN >ÍN ÆlW b÷D
t>kRµ¶ bdrsbT ¾Óßƒ xdU MKNÃT ?Ywt$ b¥lû l!kfL y¸gÆWN
ym=rš የሞት µœ KFÃ BR b²ÊW :lT k?
BrT x!N¹#‰NS x.¥. ¨ÉÎ“ ðpÎ mqbl@N XNÄ!h#M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ
bt=¥¶M l@§ w‰> n" ÆY b!mÈ bêb!nT yM-yQ mçn#N bðR¥ü xrUGÈlh#ÝÝ
SM SM
ðR¥. . ðR¥. .
Disa/Disch.F/M1
qN . . qN . .
X¥®C¿
X’@ eT@ kz!H b¬C yt-qsW w¼é¼xè k§Y yt-qsWN SMMnT
. ¨ÉÎ“ ðpÎ
mfrT@” XNÄ!h#M BR
k?BrT x!N¹#‰NS x.¥.mqbK?” ›[ÒÓ×KG<ÝÝ
SM ðR¥
1. .
2. . .
3. .

ymt¥m¾ \nD
X ኔ S»¼ kz!H b¬C ytgliW¿ y w§J xúÄ ጊ SçN¿ ሟች አቶ
b ›..M. b?BrT x!N¹#‰NS ymDN >ÍN ÆlW b÷D t>kRµ¶ bdrsbT
y ግጭት xdU MKNÃT ?Ywa¼t$ b¥lÐ¼û l!kfL y¸gÆWN ym=rš µœ KFÃ BR
b²ÊW :lT k?BrT x!N¹#‰NS x.¥.wdNÂ fQdN
mqbl@N¼§CNN XNÄ!h#M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#
‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ¼y¥N-YQ mçn@N¼mçÂCNN
bt=¥¶M l@§ w‰> n" ÆY b!mÈ bêb!nT yM-yQ¼ yMN-yQ mçn#N bðR¥ü¼CN xrUGÈlh#¼
XÂrUGÈlNÝÝ
SM SM
ðR¥. . ðR¥. .
Disa/Disch.F/M1
qN . . qN . .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .
ymt¥m¾ \nD
Xn@ S» kz!H b¬C ytgliW¿ y Ælb@T ?UêE w‰> SçN¿
t-”¹# b ›.M. b?BrT x!N¹#‰NS ymDN >ÍN ÆlW b÷D
t>kRµ¶ bdrsbT yG+T xdU MKNÃT ?Ywt$ b¥lû l!kfL y¸gÆWN ym=rš yäT µœ KFÃ BR
. b²ÊW :lT k?BrT x!N¹#‰NS x.¥.
wDËÂ fQË mqbl@N XNÄ!ሁ M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#
‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ mçn@N bt=¥¶M l@§ w‰> n"
ÆY b!mÈ bêb!nT yM-yQ mçn@N bðR¥ü xrUGÈlh#ÝÝ
SM
ðR¥. .
qN . .
Disa/Disch.F/M1
X¥®C¿
X¾ S¥CN kz!H b¬C yt-qsW X¥®C w¼é¼xè . k§Y yt-qsWN SMMnT
wdWÂ fQdW mfr¥cWN ና XNÄ!h#M BR k?BrT x!
SM ðR¥
1. .
2. . .
3. .
ymt¥m¾ \nD
Xn@ S» kz!H b¬C yt-qsW¿ y w§J XÂTÂ xúÄg!
SçN¿ LË b ›.M y\l@Ä q$_„ bçnÂ b?BrT x!N¹#
‰NS ymDN >ÍN ÆlW t>kRµ¶ bdrsbT yG+T xdU MKNÃT ldrsbT yxµL g#ÄT kçSpE¬L bts-
W y»Ä!µL ïRD sRtFk@T m\rT l!kfL y¸gbWN ym=rš yµœ KFÃ BR
b²ÊW :lT k?BrT x!N¹#‰NS x.¥. wDËÂ fQË mqbl@N XNÄ!h#M YHNN xdU btmlkt MNM
›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-
YQ mçn@N bðR¥ü xrUGÈlh#ÝÝ
SM
ðR¥. .
qN . .
Disa/Disch.F/M1
X¥®C¿
SM ðR¥
1. .
2. . .
3. .

ymt¥m¾ \nD ¼dNb¾¼
\l@Ä q$_R ¿ .
ätR q$_R ¿
Òs! q$_R ¿
êSTÂ q$_R ¿ yµœ q$_R¿
y\l@Ä q$_„ k§Y yt-qW t>kRµ¶ bdrsbT xdU MKNÃT k_QM W+ bmçn#¿ b?BrT x!N¹‰NS
x.¥ Æl ዉ ymDN >ÍN m\rT yx-”§Y WDmT yµœ KFÃ BR
b²ÊW :lT k?BrT x!N¹#‰NS x.¥.
ytqbL ኩ s!çN bz!H xdU ydrsWN g#ÄT btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#‰NS
x.¥. y¥ን-YQ mçn@N bðR¥ችን rUGÈl ን በተጨማሪም በመኪናዉ ጉዳይ ይገባኛል ብሎ የሚመጣ
ማንኛዉም አካል ቢኖር ሀላፊነቱን የማንወስድ መሆኑን በፊርማችን
Disa/Disch.F/M1
¬HúS 08 qN 1999 ›.M. y\l@Ä q$_„ 3-01141 bçnW t>kRµ¶ §Y ÆdrsW g#ÄT
MKNÃT y\l@Ä q$_„ 3-01141 yçnW t>kRµ¶ k_QM W+ bmçn# kQ¶t$ GMT §Y y‰s@N DRš
BR 53,478.49 (¦Mú ƒST ¹!H x‰T mè sÆ SMNT BR k49¼100) b²ÊW qN bc&K q$_R
BB1022119 ytqbLk# mçn@N XÃrUG_k# µh#N b“§ bQ¶t$ §Y MNM ›YnT t=¥¶ _Ãq& y¥§qRB
SM ðR¥. .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .

ymt¥m¾ \nD
Xn@ xè ytÆLk# GlsB b . ›.M. b?
BrT x!N¹#‰NS ymDN >ÍN ÆlW b÷D t>kRµ¶ §drsB" yxµL g#ÄT
kçSpE¬L bts-" y»Ä!µL ïRD sRtðk@T l!kfl" y¸gÆWN ym=rš yµœ KFÃ BR .
b²ÊW :lT k?BrT x!N¹#‰NS

k#ÆNÃ x.¥. wDËÂ fQË mqbl@N XNÄ!h#M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq&
Disa/Disch.F/M1
k?BrT x!N¹#‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ mçn@N bðR¥ü
xrUGÈlh#ÝÝ
SM
ðR¥
qN
X¥®C¿
SM ðR¥
1. .
2. . .
3. .

ymt¥m¾ \nD
Xn@¼X¾ S»¼S¥CN kz!H b¬C ytgliW¿ y w¼é n#¶Ã ys#F x!B‰£M w§J¼íC¼ xúÄg!¼?UêE
w‰> SçN¼SNçN¿ t-”š*¼¹# b 12¼02¼2000 ›..M. b?BrT x!N¹#‰NS ymDN >ÍN ÆlW
b÷D 3-10942 t>kRµ¶ bdrsbT¼ÆT yG+T xdU MKNÃT ?Ywa¼t$ b¥lÐ¼û l!kfL y¸gÆWN
ym=rš µœ KFÃ BR 23,000 (¦Ã ƒST ¹!H BR) b²ÊW :lT k?BrT x!N¹#‰NS x.¥. wdNÂ fQdN
mqbl@N¼§CNN XNÄ!h#M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#
‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ¼y¥N-YQ mçn@N¼mçÂCNN
bt=¥¶M l@§ w‰> n" ÆY b!mÈ bêb!nT yM-yQ¼ yMN-yQ mçn#N bðR¥ü¼CN xrUGÈlh#¼
XÂrUGÈlNÝÝ
Disa/Disch.F/M1
SM xè xBd§ x!B‰£M m/mD SM
ðR¥. . ðR¥. .
qN . . qN . .
X¥®C¿
X¾ S¥CN kz!H b¬C yt-qsW X¥®C w¼é¼xè xBd§ x!B‰£M m/mD k§Y yt-
.
qsWN SMMnT wdWÂ fQdW mfr¥cWN XNÄ!h#M BR 23,000.00 (¦Ã ƒST ¹!H BR)
k?BrT x!N¹#‰NS x.¥.mqb§cWN ¥y¬CNN XÂrUGÈlNÝÝ
SM ðR¥
1. .
2. . .
3. .
yµ¥ KFÃ SMMnT

b?BrT x!N¹#‰NS k#ÆNÃ x.¥ ymDN >ÍN yts-W y\l@Ä q$_„ .
yçn yxè¼ w¼é t>kRµ¶ b ›.M. bxè rÄ! \
YD §Y yG+T xdU b¥Drs# xSf§g!WN HKMÂ s!k¬tl# yö† b!çNM xh#N GN bÆ?§êE HKMÂ
lm-qM Slflg# yµœ KFÃWN BR
b²ÊW :lT bc&K q$_R ! ktgÖ©!W bts-W ?UêE WKLÂ m\rT
ytqbLk# Slçn kxh#N b“§ k?BrT x!N¹#‰NS x.¥ çn kt>kRµ¶W Ælb@TÂ ëØR MNM ›YnT t=¥¶
KFÃ y¥L-YQ mçn@N bðR¥ü xrUGÈlh#ÝÝ
SM
Disa/Disch.F/M1
ðR¥. .
qN . .
ymt¥m¾ \nD
Xn@ S» kz!H b¬C yt-qsW¿ b ›.M \l@Ä
q$_„ bçnÂ b?BrT x!N¹#‰NS ymDN >ÍN ÆlW t>kRµ¶ bdrsbT yG+T xdU MKNÃT
ldrsbT yxµL g#ÄT kçSpE¬L bts-W y»Ä!µL ïRD sRtFk@T m\rT l!kfL y¸gbWN ym=rš yµœ
KFÃ BR b²ÊW :lT k?BrT x!N¹#‰NS x.¥.
wDËÂ fQË mqbl@N XNÄ!h#M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#
‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ mçn@N bðR¥ü xrUGÈlh#ÝÝ
SM
ðR¥. .
qN . .
Disa/Disch.F/M1
X¥®C¿
SM ðR¥
1. .
2. . .
3. .
WK?Ç lØ`___________________________________
V}` lØ` __________________________________________
‰c= lØ` ___________________________________________
ªeƒ“ lØ`_______________ ¾"X lØ`__________
Xn@ S» kz!H b¬C yt-qsW ZRZ„ kz!H b§Y yt-qsW }iŸ`"¶ ÆlNBrT SçN¿ k§Y yt-qsW t>kRµ¶
k” ¯.M. u¡MM ¨[Ç M¿ eS< u}vK x uÅ[cuƒ ›ÅÒ t>kRµ¶WN l¥S-gN
¨ß¨<” w` ________________________________________ b²ÊW XlT k?BrT x!N¹#‰NS x.¥.
eK}kuMŸ<& u²=I ›ÅÒ UŸ”Áƒ U”M xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T ¾TMÖÃp SJ’@”
u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</“[ÒÓ×K”::
k”_______________________________ ò`T_______________________
Disa/Disch.F/M1
T™‹
1.
_________________________________________ ò`T_______________________
2. _________________________________________ ò`T_______________________
3. _________________________________________ ò`T_______________________
ymt¥m¾ \nD
Xn@ S» kz!H b¬C yt-qsW¿ b ›.M \l@Ä
q$_„ bçnÂ b?BrT x!N¹#‰NS ymDN >ÍN ÆlW t>kRµ¶ bdrsbT yG+T xdU MKNÃT
ldrsbT yxµL g#ÄT ለሰሜን ሸዋ ዞን ከፍተኛ ፍርድ ቤት እንዲሁም በኦሮሚያ ጠቅላይ ፍ/ቤት የጉዳት µœ
KFÃ BR b²ÊW :lT k?BrT x!N¹#‰NS x.¥.
wDËÂ fQË mqbl@N XNÄ!h#M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#
‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ እና የተከፈተውን የአፈፃፀም መዝገብ
ቁጥር ---------------------- የምዘጋ mçn@N bðR¥ü xrUGÈlh#ÝÝ
SM
ðR¥. .
qN . .
X¥®C¿
SM ðR¥
1. .
Disa/Disch.F/M1
2. . .
3. .
የመተማመኛ ሰነድ
እኔ አቶ ------------------------------------------------------ንብረትነቱ የአቶ -------------------------------- ሠሌዳ

ቁጥር ---------------------------- የሆነና የሕብረት ኢንሹራንስ አ/ማ የዋስትና ሽፋን ባለው ተሽከርካሪ
በ------------------- ቀን -------------- ዓ.ም በግጭት በአካሌ ላይ ባደረሰበኝ ጉዳት መሠረት የአፋር ክልል የዞን 3
ከፍተኛ ፍ/ቤት በ------------ ቀን --------------- ዓም በዋለው ችሎት ብር 30,000.00 (ሰላሳ ሺ ብር) የካሣ ክፍያ
ሕብረት ኢንሹራንስ አ.ማ እንዲከፍለኝ በወሰነው መሠረት ይህንኑ ክፍያ እማኞች ባሉበት ከሕብረት ኢንሹራንስ
አ.ማ ተወካይ ከሌ/ኮለኔል ታምራት ነጋሽ እጅ ቆጥሬ የተረከብኩ ሲሆን ይህንኑ አደጋ በተመለከተ ምንም አይነት
ተጨማሪ የካሣ ጥያቄ ከሕብረት ኢንሹራንስ አ.ማ ሆነ ከባለንብረቱ ከአቶ
-----------------------------------የማልጠይቅ መሆኔን በፊርማዬ አረጋግጣለሁ፡፡
ስም አድራሻ ፊርማ ቀን
---------------------------------- ----------------------------- ------------------- ---------------
እማኞች
እኛ ስማችን ከዚህ በታች የተጠቀሰው እማኞች ከላይ የተጠቀሰውን ስምመነት ሁለቱም ወገኖች ወደውና ፈቅደው
ሲፈፅሙና ሲፈርሙ ማየታችንን በፊርማችን እናረጋግጣለን፡፡
ስም አድራሻ ፊርማ ቀን
1. ------------------------------- ----------------------- --------------------- ------------------

2. ------------------------------ ---------------------- -------------------- ------------------
3. ------------------------------ ----------------------- ---------------------- -----------------
Disa/Disch.F/M1
ymt¥m¾ \nD
yçnWÂ y\l@Ä q$_„ yçn t>kRµ¶ ልዩ ቦታው ________________ ቀበሌ

___________ ወረዳ ___________ b ንብረት §Y ÆdrsW yG+T xdU
MKNÃT በኢንሹራንሱ l!kfL y¸gÆWN በአራት ሰዎች ላይ በደረሰዉ የግጭት አደጋ ለህክምና ያወጡትን
ወጪ የካሣ መጠን BR
b²ÊW :lT k?BrT x!N¹#‰NS k#ÆNÃ x.¥. በቼክ ቁጥር ____________________ wDËÂ fQË
mqbl@N Xygl{k#¿ XNÄ!h#M bîSt¾ wgN t>kRµ¶ §Y ldrsý g#ÄT y¥Stg¾ êU BR
wDËÂ fQË mqbl@N Xygl{N YHNN xdU btmlkt bîSt¾ wgN
l¸mÈ ¥N¾ýNM _Ãq& ¦§ðnt$N XNdMNwSD Xygl{N MNM ›YnT t=¥¶ yµœ _Ãq& ከ?BrT x!
N¹#‰NS x.¥. y¥L-YQ mçn@N bðR¥ü xrUGÈlh#ÝÝ
SM
ðR¥. .
qN . .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< __________________________________________________________ u}vK x
በተሽከርካሪዬ ላይ uÅ[c ብኝ ›ÅÒ U¡”Áƒ በአሌልቱ ወረዳ ፍርድ ቤት በተሰጠው ውሳኔ መሰረት የፍርድ
ባለዕዳው ሊከፍል የሚገባውን w`___________________________________eK}kuMŸ<&u²=I ›ÅÒ
UŸ”Áƒ ም ሆነ በፍርድ ቤት ውሳኔ መሠረት MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T J’ ŸÅ”u—‹G<
ŸWK?Ç lØ` SŸ=“ vKu?ƒ“ ›iŸ`"] ¾TMÖÃp SJ’@”ና እንዲሁም በአሌልቱ ወረዳ ፍርድ
ቤት የከፈትኩትን የአፈፃፀም ክስ በችሎት ቀርቤ አዘጋለሁ፡፡ ይህንንም u}KSÅ¨< ò`TÂ/ò`T‹”
›[ÒÓ×KG</“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< __________________________________________________________ u}vK x ታ
uÅ[cuƒ ›ÅÒ U¡”Áƒ KTW^ƒ ¨ß¨<” w`___________________________________
eK}kuMŸ<&u²=I ›ÅÒ UŸ”Áƒ MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T J’ ŸÅ”u—‹G< ŸWK?Ç lØ`
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
ymt¥m¾ \nD
Xn@ S» kz!H b¬C yt-qsW y\l@Ä q$_R ¾J’ V}` u=eŸK?ƒ
Ælb@T yçNk# b ›.M V}` u=eŸK?~ bdrsbT xdU MKNÃT k_QM
W+ bmçn#¿ b?BrT x!N¹‰NS x.¥ Æl" ymDN >ÍN m\rT yx-”§Y WDmT yµœ KFÃ BR
b²ÊW :lT k?BrT x!N¹#‰NS x.¥. ytqbLk# s!çN bz!H xdU ydrsWN g#ÄT btmlkt MNM ›YnT
t=¥¶ yµœ _Ãq& k?BrT x!N¹#‰NS x.¥. y¥L-YQ mçn@N bðR¥ü xrUGÈlh#ÝÝ
SM
ðR¥. .
qN . .
X¥®C¿
X¾ S¥CN kz!H b¬C yt-qsW X¥®C xè¼w¼é¼T k§Y yt-qsWN SMMnT
SM ðR¥
1. .
2. . .
3. .
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< __________________________________________________________ u}vK
x ታuÅ[cuƒ ›ÅÒ U¡”Áƒ x-”§Y WDmT SldrsbT k?BrT x!N¹#‰NS x.¥ yµœ KFÃ
w`___________________________________
eK}kuMŸ<&u²=I ›ÅÒ UŸ”Áƒ MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T ¾TMÖÃp SJ’@” u}KSÅ¨<
ò`TÂ/ò`T‹” ›[ÒÓ×KG</እ“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
WK?Ç lØ`:_____________________________________
V}` lØ`: __________________________________________
‰c= lØ`: ___________________________________________
ªeƒ“ lØ`: _______________ ¾"X lØ`: ___________

ስሙ_______________________ በተባለ ቦታ የመገልበጥ አደጋ የደረሰበት ቢሆንም በህግ ውሉ መሰረት
¾›=”g<^”e ió” እ”ÅK?K¨< ¾}[ÒÑÖ uSJ’< vK” ¾e^ Ó”–<’ƒ SW[ƒ ›e}Á¾ƒ እ”Ç=Å[ÓM˜ uÖ¾Ÿ<ƒ
Sc[ƒ ብር____________________ስለተቀበልኩ በዚህ አደጋ ምክንያት ምንም አይነት ተጨማሪ ካሣ ከሕብረት
ኢንሹራንስ አ.ማ የማልጠይቅ መሆኔን በተለመደው ፊርማዬ/ፊርማችን አረጋግጣለሁ/እናረጋግጣለን፡፡
k”_______________________________ ò`T_____________________
T™‹
1. _________________________________________
ò`T_____________________
2. _________________________________________ ò`T____________________
3. _________________________________________ ò`T_____________________

Disa/Disch.F/M1
WK?Ç lØ`:_____________________________________
V}` lØ`: __________________________________________
‰c= lØ`: ___________________________________________
ªeƒ“ lØ`: _______________ ¾"X lØ`: ___________

ስሙ_________________________ በተባለ ቦታ በደረሰበት አደጋ U¡”Áƒ ¾ØÑ“ ¨Ü¨< ”Ç=ŸðK˜ uÖ¾Ÿ<ƒ
SW[ƒ ›ÖnLÃ ¾ØÑ“ ¨Ü ብር _______________________ስለተቀበልኩ በዚህ አደጋ ምክንያት ምንም አይነት
ተጨማሪ ካሣ ከሕብረት ኢንሹራንስ አ.ማ የማልጠይቅ መሆኔን በተለመደው ፊርማዬ/ፊርማችን
k”_______________________________ ò`T_____________________
T™‹
1. _________________________________________
ò`T_____________________
2. _________________________________________ ò`T____________________
3. _________________________________________ ò`T_______________________
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< ___________________________________ u}vK x uÅ[c¨< ¾Óßƒ ›ÅÒ U¡”Áƒ
KÅ[c¨< ¾Vƒ ›ÅÒ ¾Vƒ "X ¡õÁ w`___________________________eK}kuMŸ<&u²=I ›ÅÒ UŸ”Áƒ
MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T J’ ŸÅ”u—‹G< ŸWK?Ç lØ`
-----------------------------SŸ=“ vKu?ƒ“ ›iŸ`"] ¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹”
›[ÒÓ×KG</“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
WK?Ç lØ`:_____________________________________
V}` lØ`: __________________________________________
‰c= lØ`: ___________________________________________
ªeƒ“ lØ`: _______________ ¾"X lØ`: ___________

ስሙ_________________________ በተባለ ቦታ በደረሰበት አደጋ U¡”Áƒ ¾ØÑ“ ¨Ü¨< ”Ç=ŸðK˜ uÖ¾Ÿ<ƒ
SW[ƒ ›ÖnLÃ ¾ØÑ“ ¨Ü ብር _______________________ስለተቀበልኩ በዚህ አደጋ ምክንያት ምንም አይነት
k”_______________________________ ò`T_____________________
T™‹
1. _________________________________________
ò`T_____________________
2. _________________________________________ ò`T____________________
3. _________________________________________ ò`T_______________________
mt¥m¾ c’É ¼fe}— ¨Ñ”¼
WK?Ç lØ` : _____________________________________
Disa/Disch.F/M1
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< ______ u}vK x uÅ[c¨< ¾Óßƒ ›ÅÒ U¡”Áƒ KÅ[c¨< ¾ እንስሳት የ Vƒ ›ÅÒ ተገቢውን
"X ¡õÁ w` ___________________________eK}kuMŸ<&u²=I ›ÅÒ
UŸ”Áƒ MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T J’ ŸÅ”u—‹G< ŸWK?Ç lØ` SŸ=“
vKu?ƒ“ ›iŸ`"] ¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
WK?Ç lØ`:_____________________________________
Disa/Disch.F/M1
V}` lØ`: __________________________________________
‰c= lØ`: ___________________________________________
ªeƒ“ lØ`: _______________ ¾"X lØ`: ___________

ስሙ_______________________ በተባለ ቦታ በደረሰበት ¾e`qƒ አደጋ አስፈላጊው ጥገና
”Ç=Å[ÓKƒ ወጭውን ብር ___________________________________________ስለተቀበልኩ በዚህ አደጋ
ምክንያት ምንም አይነት ተጨማሪ ካሣ ከሕብረት ኢንሹራንስ አ.ማ የማልጠይቅ መሆኔን በተለመደው
ፊርማዬ/ፊርማችን አረጋግጣለሁ/እናረጋግጣለን፡፡
k”_______________________________ ò`T_____________________
T™‹
1. _________________________________________
ò`T_____________________
2. _________________________________________ ò`T____________________
3. _________________________________________ ò`T_____________________
mt¥m¾ c’É
Disa/Disch.F/M1
WK?Ç lØ` : 2-99462
V}` lØ` : SCP10-0107651
‰c= lØ` : 152-0254344
ªeƒ“ lØ` : P-24-00071 ¾"X lØ` : P-24-01337/10
ŸLÃ ¾cK?Ç lØ\ ¾}Ökc¨< }iŸ`"] ulØ` P-24-00071 ªeƒ“ ¾}ÑvKƒ c=J” SeŸ[U 15 k” 2003 ¯.M. ¾Óßƒ
›ÅÒ Å`fuƒ u›ÖnLÃ ¨ÉSƒ ”Ç=e}“ÑÉ S¨c’< Ã¨dM::
’Ñ` Ó” ¾}iŸ`"]¨< ¾V}` lØ` KT”uw ›e†Ò] uSJ’< ¾V}` lØ\ uK=w_¨< LÃ Ÿ}Ökc¨< ¨<ß u=J” GLò’~”
S<K< uS<K< ¾UëÉ SJ’<” ›[ÒÓ×KG<::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< __________________________________________________________ u}vK x
uÅ[cuƒ ›ÅÒ U¡”Áƒ x-”§Y WDmT SldrsbT k?BrT x!N¹#‰NS x.¥ yµœ KFÃ
w`___________________________________eK}kuMŸ<&u²=I ›ÅÒ UŸ”Áƒ MNM xYnT t=¥¶ "X
ŸQw[ƒ ›=”g<^”e ›T ¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< __________________________________________________________ u}vK x ታ
vÅ[c¨< ¾”w[ƒ ›ÅÒ U¡”Áƒ xeðLÑ>¨< ¾ØÑ“ ¨Ü w`___________________________________
eK}kuMŸ<&u²=I ›ÅÒ UŸ”Áƒ MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T J’ ŸÅ”u—‹G< ŸWK?Ç lØ`
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________

Disa/Disch.F/M1
WK?Ç lØ`:_____________________________________
V}` lØ`: __________________________________________
‰c= lØ`: ___________________________________________
ªeƒ“ lØ`: _______________ ¾"X lØ`: ___________

k”_______________________________ ò`T_____________________
T™‹
1. _________________________________________
ò`T_____________________
2. _________________________________________ ò`T____________________
3. _________________________________________ ò`T_______________________
ymt¥m¾ \nD
Xn@ S» kz!H b¬C ytgliW¿ y xè ፋ@ ¸dQú xÃñ Ælb@T ?UêE w‰> SçN¿ t-”¹# b05¼03¼2033
›..M. b?BrT x!N¹#‰NS ymDN >ÍN ÆlW b÷D 3-33479 t>kRµ¶ bdrsbT yG+T xdU
Disa/Disch.F/M1
MKNÃT ?Ywt$ b¥lû l!kfL y¸gÆWN ym=rš µœ KFÃ BR 15,000 (›e^ ›Ueƒ ¹! BR) b²ÊW :lT k?
BrT x!N¹#‰NS x.¥. ¨ÉÎ“ ðpÎ mqbl@ XNÄ!h#M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ
bt=¥¶M l@§ w‰> n" ÆY b!mÈ bêb!nT yM-yQ¼ mçn#N bðR¥ü xrUGÈlh# ÝÝ
SM
ðR¥. .
qN . .
X¥®C¿
X¾ S¥CN kz!H b¬C yt-qsW X¥®C w¼é .k§Y yt-qsWN SMMnT wdWÂ
fQdW mfr¥cWN XNÄ!h#M BR 15,000 (›e^ ›Ueƒ ¹! BR) k?BrT x!N¹#‰NS x.
¥.mqb§cWN ¥y¬CNN XÂrUGÈlNÝÝ
SM ðR¥
1. .
2. . .
3. . .
Disa/Disch.F/M1
WK?Ç lØ`:_____________________________________
V}` lØ`: __________________________________________
‰c= lØ`: ___________________________________________
ªeƒ“ lØ`: _______________ ¾"X lØ`: ___________

ስሙ_________________________ በተባለ ቦታ u አህያ LÃ vÅ[c¨< ¾Vƒ ›ÅÒ ¾"X ¡õÁ w ር
k”_______________________________ ò`T_____________________
T™‹
1. _________________________________________
ò`T_____________________
2. _________________________________________ ò`T____________________
3. _________________________________________ ò`T_______________________
ymt¥m¾ \nD ¼fe}— ¨Ñ”¼
\l@Ä q$_R ¿ .
ätR q$_R ¿
Òs! q$_R ¿
Disa/Disch.F/M1
êSTÂ q$_R ¿ yµœ q$_R¿
b?BrT x!N¹#‰NS k#ÆNÃ x.¥ ymDN >ÍN yts-W y\l@Ä q$_„ .

yçn yxè¼ w¼é t>kRµ¶ b ›.M. ÆdrsB˜ xdU MKNÃT
xSf§g!WN HKMÂ ¾Ú[eŸ< c=J” u³_¨< °Kƒ ’@ ›„/¨/a-------------------------- u k”
¯.U w` ------------------------ስለተቀበልኩ በዚህ አደጋ ምክንያት ምንም አይነት ተጨማሪ
ካሣ ከሕብረት ኢንሹራንስ አ.ማ J’ ŸÅ”u—‹G< ŸWK?Ç lØ` SŸ=“ vKu?ƒ“ ›iŸ`"]
¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</“[ÒÓ×K”::
SM ðR¥. .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .
WK?Ç lØ` : _____________________________________
Disa/Disch.F/M1
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
”w[ƒ’~ ¾ ¾J’ ´`´\ ŸLÃ ¾}Ökc¨< }iŸ`"]Â u k” ¯.M.

u¡MM ¨[Ç M¿ eS< __________________________________________________________
ufe}— ¨Ñ” LÃ uÅ[c¨< ¾Óßƒ ›ÅÒ U¡”Áƒ IÃ¨~ TKñ Ã¨dM:: uSJ’<U ’@ ¾}iŸ`"]¨< vKu?ƒ Kfe}—
¨Ñ” ¾ŸðMŸ<ƒ” k?BrTx!N¹#‰NS x.¥ w`___________________________________ u³_¨< ›Kƒ
eK}kuMŸ<&u²=I ›ÅÒ UŸ”Áƒ MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T ¾TMÖÃp SJ’@” u}KSÅ¨<
ò`TÂ/ò`T‹” ›[ÒÓ×KG</“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
ymt¥m¾ \nD
Xn@ S» kz!H b¬C ytgliW¿ y Ælb@T ?UêE w‰> SçN¿
t-”¹# b ›.M. b?BrT x!N¹#‰NS ymDN >ÍN ÆlW b÷D
t>kRµ¶ bdrsbT xdU MKNÃT ?Ywt$ b¥lû l!kfL y¸gÆWN yäT µœ KFÃ BR
Disa/Disch.F/M1
. b²ÊW :lT k?BrT x!N¹#‰NS x.¥. wDËÂ fQË
mqbl@N XNÄ!ሁ M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#‰NS x.¥. çn
kt>kRµ¶W ÆlNBrT y¥L-YQ mçn@N bt=¥¶M l@§ w‰> n" ÆY b!mÈ bêb!nT yM-yQ mçn@N
SM
ðR¥. .
qN . .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .
ymt¥m¾ \nD
እ’@ eT@ kz!H b¬C ytgliW¿ y ?UêE w‰> eJ”¿ t-”¹# b
›.M. b?BrT x!N¹#‰NS ymDN >ÍN ÆlW b÷D
t>kRµ¶ bdrsbT xdU MKNÃT ?Yw$~/… b¥lû l!kfL y¸gÆWN yäT µœ KFÃ BR
. b²ÊW :lT k?BrT x!N¹#‰NS x.¥. wDËÂ fQË
mqbl@N XNÄ!ሁ M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#‰NS x.¥. çn
Disa/Disch.F/M1
kt>kRµ¶W ÆlNBrT y¥L-YQ mçn@N bt=¥¶M l@§ w‰> n" ÆY b!mÈ bêb!nT yM-yQ mçn@N
SM
ðR¥. .
qN . .
X¥®C¿
SM ðR¥
1. .
2. . .
3. .
mt¥m¾ c’É ¼dNb¾¼
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
Disa/Disch.F/M1
¨[Ç M¿ eS< __________________________________________________________ u}vK x
uÅ[cuƒ ›ÅÒ U¡”Áƒ Kfe}— ¨Ñ” ¾ŸðMŸ<ƒ” ¾I¡U“ ¨Ü
w`------------------------------------------------------------------------------- SkuK?” u}KSÅ¨< ò`TÂ/ò`T‹”
›[ÒÓ×KG</“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
ymt¥m¾ \nD
— cT‹” kz!H b¬C ytgliW¿ ¾Ií” ›=U^” c=^Ï ?UêE w‰> e”J”¿ t-” b23/01/2004 ›.M. b?BrT
x!N¹#‰NS ymDN >ÍN ÆlW b÷D 3-16662 *a t>kRµ¶ bdrsbT yG+T xdU MKNÃT QÃ¨…
¥lû l!kfL y¸gÆWN ym=rš µœ KFÃ BR 10,000 (›e` ¹! BR) b²ÊW :lT k?BrT x!N¹#‰NS x.¥.
¨Å”“ ðkÅ” SkuL‹”” XNÄ!h#M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT x!N¹#
‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥”-YQ SJ“‹”” bt=¥¶M l@§ w‰> n" ÆY
b!mÈ bêb!nT yM”-yQ¼ mçn#N bðR¥‹” xrUGÈlh# ÝÝ
Disa/Disch.F/M1
SM ›„ c=^Ï vÃX ðR¥. .
¨/a û=Á TIS<É ðR¥. .
qN . .
X¥®C¿
X¾ S¥CN kz!H b¬C yt-qsW X¥®C ›„ w¼é
.k§Y yt-qsWN SMMnT wdWÂ fQdW mfr¥cWN XNÄ!h#M BR 10,000 (›e` ¹! BR)
k?BrT x!N¹#‰NS x.¥.mqb§cWN ¥y¬CNN XÂrUGÈlNÝÝ
SM ðR¥
1. .
2. . .
3. . .
mt¥m¾ c’É ¼Å”u—¼
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
Disa/Disch.F/M1
¨[Ç M¿ eS< ___________________________________ u}vK x uÅ[c¨< ¾fe}— ¨Ñ” ¾Óßƒ
›ÅÒ U¡”Áƒ ¾I¡U“ ¨Ü w`___________________________eK}kuMŸ<&u²=I ›ÅÒ UŸ”Áƒ MNM xYnT
t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T ¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
የመተማመኛ ሰነድ (fe}— ¨Ñ”)
WK?Ç lØ`:_____________________________________
V}` lØ`: __________________________________________
‰c= lØ`: ___________________________________________
ªeƒ“ lØ`: _______________ ¾"X lØ`: ___________
Disa/Disch.F/M1
ስሙ_________________________ በተባለ ቦታ በ Å[c¨< ¾fe}— ¨Ñ” ¾Óßƒ ›ÅÒ ወጭውን ብር
ተጨማሪ ካሣ ŸQw[ƒ ›=”g<^”e ›T J’ ŸÅ”u—‹G< ŸWK?Ç lØ` ------------------------------------SŸ=“
vKu?ƒ“ ›iŸ`"] ¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</“[ÒÓ×K”::
k”_______________________________ ò`T_____________________
T™‹
1. _________________________________________
ò`T_____________________
2. _________________________________________ ò`T____________________
3. _________________________________________ ò`T_______________________
WK?Ç lØ`:_____________________________________
V}` lØ`: __________________________________________
Disa/Disch.F/M1
‰c= lØ`: ___________________________________________
ªeƒ“ lØ`: _______________ ¾"X lØ`: ___________

k”_______________________________ ò`T_____________________
T™‹
1. _________________________________________
ò`T_____________________
2. _________________________________________ ò`T____________________
3. _________________________________________ ò`T_______________________
WK?Ç lØ` : 3-38411 ›.›
Disa/Disch.F/M1
V}` lØ` : E483TD6D140708
‰c= lØ` : MC223ECL761136154
¾¨<M lØ` : GU/24//1022/2011/00249 ¾"X TIÅ` lØ` : GC/24//1022/2011/00015
uŸ<v”Á¨< ¾}iŸ`"] SÉ” ¨<M lØ` GU/24//1022/2011/00249 ió” ¾}cÖ¨< cK?Ç lØ` 3-38411
›.› }iŸ`"] uÅ[cuƒ ›ÅÒ U¡”Áƒ ¾"X ØÁo ›pù? Iw[ƒ ›=”g<^”e ›.T vKuƒ Lò’ƒ Ò^¼‹” "Ý[} u
%EL ¾}iŸ`"]¨< ¾ØÑ“ ªÒ uØ_ Ñ”²w ”Ç=ŸðK˜ }eTU‰KG<::
uSJ’<U }iŸ`"]Â” ’@ uðKŸ<ƒ Ò^» Lò’~” ëÎ TeÖÑ” ”É‹M u}¨c’M˜ SW[ƒ ¾`Ï“ Sª“
¾›ÅÒ S’h }k”f u³_¨< °Kƒ ŸQw[ƒ ›=”g<^”e ›.T KSkuM eeTT }ÚT] ¡õÁ ¾K?K˜“ uT“†¨<U
SMŸ< ¾Tkù¨< ¾¡õÁ ØÁo ›KS•\” ÁKU”U }ê°• ¨ÉÎ ¾}eTTG< c=J” ¾}iŸ`"]¨<”U p]ƒ Ÿ›ÅÒ¨< u
%EL vKuƒ G<’@ ¾}[ŸwŸ< c=J” K²=I }gŸ`"] ¾ÑvG<ƒ ¾SÉ” ¨<MU ÁKU”U pÉS G<’@
Ÿ³_ ËUa ”Ç=c[´ SeTT‚” u}KSÅ¨< ò`TÂ ›[ÒÓ×KG<
k” _______________________________ ò`T _______________________
T™‹
__________________
________________ ò`T _______________________
__________________________________ ò`T _______________________
__________________
________________ ò`T _______________________
¾S}TS— c’É(Å”u—)
Disa/Disch.F/M1
WK?Ç lØ`: 3-11309 ›.›
V}` lØ`:-2H-1180485
‰”c= lØ`:-JTIW04J6100955872
¾¨<M lØ`:-GU/23/1022/2012/00012 ¾"X TIÅ` lØ`:- GC/23/1022/2012/00036
uŸ<v”Á¨< ¾}iŸ`"] SÉ” ¨<M lØ` GU/23/1022/2012/00012 ió” ¾}cÖ¨< cK?Ç lØ` 3-11309
›.› }iŸ`"] uÅ[cuƒ ›ÅÒ U¡”Áƒ ¾"X ØÁo ›pù? ¾›iŸ`"]¨< S”Í õnÉ QÒ© vKSJ’< U¡”Áƒ K"X
ØÁo¨< Ÿ<v”Á¨< Lò’ƒ ”ÅK?Kuƒ u}cÖ¨< ¨<M Sc[ƒ }[ÒÓ×M::
J•U uÑ³G<ƒ ¾SÉ” ¨<M Sc[ƒ ›iŸ`"]¨< QÒ© S”Í õnÉ ¾K?K¨< uSJ’< Ÿ<v”Á¨< Lò’~” ëÊ ¾"X
ØÁo¨<” KTe}“ÑÉ vÃÑÅÉU ’@ SÉ” Ñu=¨< uêG<õU J’ uÓ”v` ¾"X ØÁo¨< u›e}Á¾ƒ
”Ç=gð”M˜ ØÁo ›pù? w` 43,832.25 (›`v feƒ g= eU”ƒ S„ dLd G<Kƒ w` Ÿ25/100)
K=ŸðK˜ }eTU‰KG<::
eK²=I u²=I ¾"X ØÁo }ÚT] ¡õÁ ¾K?K˜“ uT—†¨<U SMŸ< ¾Tkù¨< ¾¡õÁ ØÁo ›KS•\”
ÁKU”U }ê°• ¨ÉÎ ¾}eTTG< c=J” ¾}iŸ`"¨<”U p]ƒ Ÿ›ÅÒ¨< uL vKuƒ G<’@ ¾}[ŸwŸ< c=J”
K²=I }iŸ`"] ¾ÑvG<ƒ ¾SÉ” ¨<MU ÁKU”U pÉS G<’@ Ÿ³_ ËUa ”Ç=c[´ SeTT‚” u}KSÅ¨<
ò`TÂ ›[ÒÓ×KG<::
k”:--------------------------------- ò`T:- ---------------------------------
T™‹
1.------------------------------------------ ò`T -------------------------------
2.------------------------------------------ ò`T -------------------------------
3.------------------------------------------ ò`T -------------------------------
Disa/Disch.F/M1
k” _______________________
በ 04/10/12 የሰሌዳ ቁጠሩ 3-50818 ኢት Iveco ተሽከርካሪ አደጋ ደርሶበት በህብረት ኢንሹራንስ ሪከቨሪ ሳይት
እንደሚገኝ ይታወቃል፡፡ ነገር ግን ከአካል ስራ በፊት የሜካኒካል ፍተሻ (Mecanical Assesment) እንዲደረግ የተወሰነ
መሆኑ ከሪከቨሪ ሳይት ወጥቶ እኔ በመረጠኩት--------------------------------------------ጋራዥ ተፈቶ እንዲታይልኝ
የተሰማማሁ መሆኔን በፊርማዬ እረጋግጣለሁ፡፡
ò`T _______________ ስም--------------------------------- k” _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< __________________________________________________________ u}vK
x ታuÅ[cuƒ ›ÅÒ U¡”Áƒ x-”§Y WDmT SldrsbT k?BrT x!N¹#‰NS x.¥ yµœ KFÃ
w`__________________________________________________________ስለተቀበልኩ በዚህ አደጋ
ምክንያት ምንም አይነት ተጨማሪ ካሣ ከሕብረት ኢንሹራንስ አ.ማ የማልጠይቅ መሆኔን በተለመደው
ፊርማዬ/ፊርማችን አረጋግጣለሁ/እናረጋግጣለን፡፡
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< _________________________u}vK x ታ uÅ[cuƒ ›ÅÒ U¡”Áƒ y_gÂ y እቃ êU
ቅድሚያ ክፍያ k?BrT x!N¹#‰NS x.¥ yµœ KFÃ w`________________________________ ተቀብያለሁ
ቀሪውን የጥገና ክፍያ ሥራው ሲጠናቀቅ ለመቀበል የተስማማሁ መሆኔን በተለመደው ፊርማዬ አረጋግጣለሁ፡፡
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________

Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< __________________________________________________________ u}vK
x ታuÅ[cuƒ ›ÅÒ U¡”Áƒ ¾ØÑ“¨<” ¨Ü k?BrT x!N¹#‰NS x.¥ yµœ KFÃ 75%
w` ŸQw[ƒ ›=”g<^”e ›T ተቀብያለሁ፡፡
k]¨<” 25% }gŸ`ካ]¨< u}cÖ¨< ¾Y^ ƒ°³´ Sc[ƒ uƒ¡¡M uSÖÑ’< k]¨<” w` u³_¨< °Kƒ ŸQw[ƒ ›=”g<^”e ›T
ተቀብያለሁ፡፡
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
WK?Ç lØ` : _____________________________________
Disa/Disch.F/M1
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
”w[ƒ’~ ¾______________________________________________________ ¾J’ ´`´\ ŸLÃ

¾}Ökc¨< }iŸ`"] k” ¯.U. u¡MM . ¨[Ç M¿ eS<
_________________________________________ u}vK x ታ uÅ[cuƒ ›ÅÒ uS[ØŸ<ƒ
Ò^» l¥\‰T bQD¸Ã y_gÂWN 50% wÀ¨<” w`__________________
y}kuMŸ< s!çN q¶WN 50% mk!ÂW ytmzgb Slçn y_gÂW |‰ m-Âqq$ k¬y b“§
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
mt¥m¾ c’É ¼ fe}— ¨Ñ”)
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< _____________ u}vK x ታ uÅ[cuƒ ›ÅÒ U¡”Áƒ u}cÖ¨< ¾Y^ ƒ°³´ Sc[ƒ ŸLÃ
¾}Ökc¨< }iŸ`ካ] xeðLÑ>¨< ØÑ“ }Å`ÔKƒ ŸÑ’ƒ ¨/›Ñ–G< Ò^» S[Ÿu?” u}KSÅ¨< ò`TÂ/ò`T‹”
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
mt¥m¾ c’É ¼ ደንበኛ/
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

¨[Ç M¿ eS< ______ u}vK x uÅ[c¨< ¾Óßƒ ›ÅÒ U¡”Áƒ KÅ[c¨< የኤሌትሪክ ምሰሶ ›ÅÒ ተገቢውን
"X ¡õÁ w` ___________________________eK}kuMŸ<&u²=I ›ÅÒ
UŸ”Áƒ MNM xYnT t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T ¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹”
›[ÒÓ×KG</“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
Disa/Disch.F/M1
ymt¥m¾ \nD
እ— cT‹” kz!H b¬C ytgliW¿ ¾ ወ/ሮ ፀዳለ ወልደአብ ?UêE w‰> e”J” ¿ t-” b15/12/2009 ›.M. b?
BrT x!N¹#‰NS ymDN >ÍN ÆlW b÷D 3-A03169 *a t>kRµ¶ bdrsÆT yG+T xdU MKNÃT
QÃ¨… u¥lû l!kfL y¸gÆWN ym=rš µœ KFÃ BR 12,441.00 (አስራ ሁለት ሺህ አራት መቶ አርባ አንድ
ብር) X¾ w‰ëC lXÃNÄÄCN ብር 3,110.25(ሶስት ሺህ አንድ መቶ አስር ከ 25/100) b²ÊW :lT k?BrT
x!N¹#‰NS x.¥. ¨Å”“ ðkÅ” SkuL‹”” XNÄ!h#M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ
_Ãq& k?BrT x!N¹#‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥”-YQ SJ“‹”” bt=¥¶M
l@§ w‰> n" ÆY b!mÈ bêb!nT yM”-yQ¼ mçn#N bðR¥‹” xrUGÈlh# ÝÝ
SM ቆንጂት እንዳለ ðR¥. .
አዳኑ እንዳለ ðR¥. .
የሺሃረግ እንዳለ ðR¥. .
አብዮት እንዳለ ðR¥. .
X¥®C¿
X¾ S¥CN kz!H b¬C yt-qsW X¥®C k§Y bSM yt-qs#T w‰ëC k§Y yt-qsWN SMMnT wdWÂ
.
fQdW mfr¥cWN XNÄ!h#M bDM„ BR 12,441.00 (አስራ ሁለት ሺህ አራት መቶ አርባ አንድ ብር) k?
BrT x!N¹#‰NS x.¥.mqb§cWN ¥y¬CNN XÂrUGÈlNÝÝ
SM ðR¥
1. .
2. . .
3. . .
Disa/Disch.F/M1
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
”w[ƒ’~ ¾______________________________________________________ ¾J’ ´`´\ ŸLÃ

¾}Ökc¨< }iŸ`"] k” ¯.U. u¡MM . ¨[Ç M¿ eS<
_________________________________________ u}vK x ታ uÅ[cuƒ ›ÅÒ uS[ØŸ<ƒ
Ò^» l¥\‰T bQD¸Ã yX”WN êU w`__________________
y}kuMŸ< s!çN q¶WN ymk!ÂWN _gÂ êU BR y_gÂW |‰ m-Âqq$ k¬y b“§
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
ymt¥m¾ \nD
Disa/Disch.F/M1
eT@ kz!H b¬C ytgliW¿ ¾ ወ/ሮ ፀዳለ ወልደአብ ?UêE w‰> eJ” ¿ t-” b15/12/2009 ›.M. b?BrT x!
N¹#‰NS ymDN >ÍN ÆlW b÷D 3-A03169 *a t>kRµ¶ bdrsÆT yG+T xdU MKNÃT QÃ¨…
u¥lû l!kfL y¸gÆWN ym=rš µœ KFÃ BR 12,441.00 (አስራ ሁለት ሺህ አራት መቶ አርባ አንድ ብር )
X¾ w‰ëC lXÃNÄÄCN ብር 3,110.25(ሶስት ሺህ አንድ መቶ አስር ከ 25/100) b²ÊW :lT k?BrT x!N¹#
‰NS x.¥. ¨ድጄ“ ðpÎ SkuK?” XNÄ!h#M YHNN xdU btmlkt MNM ›YnT t=¥¶ yµœ _Ãq& k?BrT
x!N¹#‰NS x.¥. çn kt>kRµ¶W ÆlNBrT wYM kx>kRµ¶W y¥L-YQ SJ’@” bt=¥¶M l@§ w‰>
n" ÆY b!mÈ bêb!nT yM-yQ¼ mçn#N bðR¥ü xrUGÈlh# ÝÝ
SM ðR¥. .
X¥®C¿
X¾ S¥CN kz!H b¬C yt-qsW X¥®C k§Y bSM yt-qs#T w‰> k§Y yt-qsWN SMMnT wdWÂ
.
fQdW mfr¥cWN XNÄ!h#M bDM„ BR 3,110.25 (ሦስት ሺህ አንድ መቶ አስር ብር ከ 25 ሣ.) k?BrT
x!N¹#‰NS x.¥.mqb§cWN ¥y¬CNN XÂrUGÈlNÝÝ
SM ðR¥
1. .
2. . .
3. . .
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
Disa/Disch.F/M1
¨[Ç M¿ eS< _________________________u}vK x ታ uÅ[cuƒ ›ÅÒ U¡”Áƒ S<K<¨<” y_gÂ
êUWN k?BrT x!N¹#‰NS x.¥ yµœ KFÃ w`________________________________ }kwÁKG< u}Ý]U
ÃI” }ሽከርካሪ በተመለከተ Ÿ›=”g<^”c< Ò` ¾’u[˜” þK=c= Ás[ØŸ< c=J”<&u²=I ›ÅÒ UŸ”Áƒ MNM xYnT
t=¥¶ "X ŸQw[ƒ ›=”g<^”e ›T ¾TMÖÃp SJ’@” u}KSÅ¨< ò`TÂ/ò`T‹” ›[ÒÓ×KG</እ“[ÒÓ×K”::
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
Disa/Disch.F/M1
¨[Ç M¿ eS< _________________________u}vK x ታ uÅ[cuƒ ›ÅÒ U¡”Áƒ y_gÂ yX” êU ቅድሚያ
ክፍያ በ 21/02/2010 ዓ.ም k?BrT x!N¹#‰NS x.¥ yµœ KFÃ w`____________ ____________________
ተቀብያለሁ፡፡ ቀሪውን w`________________________________ የጥገና ክፍያ ሥራው በመጠናቀቁ በዛሬው
እለት k?BrT x!N¹#‰NS x.¥ ytqbLk# mçn@N በተለመደው ፊርማዬ አረጋግጣለሁ፡፡
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
Disa/Disch.F/M1
¨[Ç M¿ eS< _________________________u}vK x ታ uÅ[cuƒ ›ÅÒ U¡”Áƒ y_gÂ ወ uýN QDm
KFÃ k?BrT x!N¹#‰NS x.¥ w`________________________________ ¾}kuMŸ< SJ’@” u}KSÅ¨<
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
Disa/Disch.F/M1
¨[Ç M¿ eS< ________________________u}vK x ታ uÅ[cuƒ ›ÅÒ U¡”Áƒ ytlê+ :” êU k?BrT x!
N¹#‰NS x.¥ yµœ KFÃ w`__________________________________ የ}kuMŸ<& SJ’@” u}KSÅ¨<
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________
WK?Ç lØ` : _____________________________________
V}` lØ` : _____________________________________
‰c= lØ` : _____________________________________
ªeƒ“ lØ` : _______________ ¾"X lØ` :___________
Disa/Disch.F/M1
¨[Ç M¿ eS< ________________________u}vK x ታ uÅ[cuƒ ›ÅÒ U¡”Áƒ ytlê+ X” êU k?BrT x!
N¹#‰NS x.¥ yµœ KFÃ w`______________ _____________________ የ}kuMŸ<& SJ’@” u}KSÅ¨<
k” _______________________________ ò`T _______________________
T™‹
______________________
____________ ò`T _______________________
__________________________________ ò`T _______________________
_____________________
_____________ ò`T _______________________

ymt¥m¾ \nD
yçnWÂ y\l@Ä q$_„ bçn t>kRµ¶ xè¼w¼é¼¶T §Y

ÆdrsWT xdU MKNÃT l!kfL y¸gÆWN የሞተ ካሳ KFÃ BR
Disa/Disch.F/M1
. b²ÊW :lT k?BrT x!N¹#‰NS k#ÆNÃ x.¥. wDËÂ fQË mqbl@N
SM
ðR¥. .
qN . .
X¥®C¿
wdWÂ fQdW mfr¥cWN XNÄ!h#M BR k?BrT x!N¹#
‰NS x.¥.mqb§cWN ¥y¬CNN XÂrUGÈlNÝÝ
SM ðR¥
1. .
2. . .
3. .
Disa/Disch.F/M1

3rd Satisfaction Disability & Discharge (Motor)

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

3rd Satisfaction Disability & Discharge (Motor)

Uploaded by

Copyright:

Available Formats

ymt¥m¾ c’É ¼dNb¾¼

WK?Ç lØ` : _____________________________________

V}` lØ` : _____________________________________

‰c= lØ` : _____________________________________

ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

”w[ƒ’~ ¾ ¾J’ ´`´\ ŸLÃ ¾}Ökc¨< }iŸ`"] k” ¯.M. u¡MM ¨[Ç

k” _______________________________ ò`T _______________________

__________________________________ ò`T _______________________

WK?Ç lØ` : _____________________________________

V}` lØ` : _____________________________________

‰c= lØ` : _____________________________________

ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

”w[ƒ’~ ¾ ¾J’ ´`´\ ŸLÃ ¾}Ökc¨< }iŸ`"] k” ¯.M. u¡MM

k” _______________________________ ò`T _______________________

__________________________________ ò`T _______________________

WK?Ç lØ` : _____________________________________

V}` lØ` : _____________________________________

‰c= lØ` : _____________________________________

ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

”w[ƒ’~ ¾ ¾J’ ´`´\ ŸLÃ ¾}Ökc¨< }iŸ`"] k” ¯.M. u¡MM

k” _______________________________ ò`T _______________________

__________________________________ ò`T _______________________

V}` lØ`: __________________________________________

‰c= lØ`: ___________________________________________

ªeƒ“ lØ`: _______________ ¾"X lØ`: ___________

ንብረትነቱ የ__________________________________________ የሆነ ዝርዝሩ ከላይ የተጠቀሰው

WK?Ç lØ` : _____________________________________

V}` lØ` : _____________________________________

‰c= lØ` : _____________________________________

ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

”w[ƒ’~ ¾______________________________________________________ ¾J’ ´`´\ ŸLÃ

k” _______________________________ ò`T _______________________

__________________________________ ò`T _______________________

WK?Ç lØ` : _____________________________________

V}` lØ` : _____________________________________

‰c= lØ` : _____________________________________

ªeƒ“ lØ` : _______________ ¾"X lØ` :___________

´`´\ ŸLÃ ¾}Ökc¨< ”w[ƒ’~ ¾ ኢንሹራንስ ኩባንያዉ ደንበኛ የ የሆነ ተሸከርካሪ ¾ እኔ በ

k” _______________________________ ò`T _______________________

__________________________________ ò`T _______________________

WK?Ç lØ` : _____________________________________

V}` lØ` : _____________________________________

‰c= lØ` : _____________________________________

ªeƒ“ lØ` : _______________ ¾"X lØ` :_____________________

”w[ƒ’~ ¾ ¾J’ ´`´\ ŸLÃ ¾}Ökc¨< }iŸ`"] k” ¯.M. u¡MM

k” _______________________________ ò`T _______________________

__________________________________ ò`T _______________________

Registration No.: ____________________________________

Engine No.: __________________________________________

Chassis No.: _________________________________________

Policy No._______________ Claim No.:___________

Registration No.: ____________________________________

Engine No.: __________________________________________

Chassis No.: _________________________________________

Policy No._______________ Claim No.:___________

?BrT x!N¹#‰NS k#ÆNÃ x.¥.

yçnWÂ y\l@Ä q$_„ bçn t>kRµ¶ xè¼w¼é¼¶T §Y

?BrT x!N¹#‰NS k#ÆNÃ x.¥.

yçnWÂ y\l@Ä q$_„ yçn t>kRµ¶ b §Y ÆdrsW yG+T

?BrT x!N¹#‰NS k#ÆNÃ x.¥.

ymt¥m¾ c’É ¼dNb¾¼

WK?Ç lØ` : _____________________________________

V}` lØ` : _____________________________________

ªeƒ“ lØ` : _____ ¾"X lØ` :_

k” _________ ò`T _

____________ ò`T _

ªeƒ“ lØ` : _____ ¾"X lØ` :_

k” _________ ò`T _

____________ ò`T _

ªeƒ“ lØ` : _____ ¾"X lØ` :_

k” _________ ò`T _

____________ ò`T _

ªeƒ“ lØ`: _____ ¾"X lØ`: _

ªeƒ“ lØ` : _____ ¾"X lØ` :_

k” _________ ò`T _

____________ ò`T _

ªeƒ“ lØ` : _____ ¾"X lØ` :_

k” _________ ò`T _

____________ ò`T _

ªeƒ“ lØ` : _ ¾"X lØ` :_______

k” _________ ò`T _

____________ ò`T _

Policy No._____ Claim No.:_

Policy No._____ Claim No.:_

k” _________ ò`T _

____________ ò`T _

Policy No._____ Claim No.:_

ªeƒ“ lØ`/Policy No._____ ¾"X lØ`/Claim No.:_

ªeƒ“ lØ`/Policy No._________ ¾"X lØ`/Claim No.:_

ªeƒ“ lØ`/Policy No._____ ¾"X lØ`/Claim No.:_

ªeƒ“ lØ`/Policy No._____ ¾"X lØ`/Claim No.:_

ªeƒ“ lØ`_____ ¾"X lØ`

ªeƒ“ lØ` : _____ ¾"X lØ` :_

k” _________ ò`T _

____________ ò`T _

ªeƒ“ lØ` : _____ ¾"X lØ` :_

k” _________ ò`T _

____________ ò`T _

ªeƒ“ lØ` : _____ ¾"X lØ` :_

k” _________ ò`T _

____________ ò`T _